*NURSING > NCLEX-RN > Saunders Review_HESI NCLEX-RN Test 2. Includes 70 QnA Plus Rationale, Test taking strategy, Level of (All)

Saunders Review_HESI NCLEX-RN Test 2. Includes 70 QnA Plus Rationale, Test taking strategy, Level of Cognitive Ability, Client Needs, Integrated Process, Content Area, Priority Concepts, Giddens Concepts, HESI Concepts and the References.

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Saunders HESI NCLEX-RN Review Test2 1.ID: 9476801282 The nurse is caring for a woman who is starting medroxyprogesterone injections for birth control. What statements by the client would indicate a ... need for further teaching? Select all that apply. A. “I may experience some weight gain.” B. “I may not have regular periods while taking this medication.” C. “I should return in approximately 6 months for my next injection.” D. “Because it is highly effective, I can use this medication for many years.” E. “Depression is a side effect, and I should let my doctor know if I experience any mood changes.” 2.ID: 9476801218 Following thyroid surgery, the nurse notes this response (refer to figure) when taking the client’s blood pressure. On further assessment, which laboratory finding would the nurse expect to find? A. Serum calcium of 8.4 mg/dL (2.1 mmol/L) B. C. Sodium level of 138 mEq/L (138 mmol/L) D. Serum potassium of 5.1 mEq/L (5.1 mmol/L) E. F. Thyroid Stimulating Hormone (TSH) of 1.5 mU/L 3.ID: 9476805570 The charge nurse on a women’s health unit is making a client room assignment. Which clients would be least appropriate to assign to share a room with a woman who is pregnant? Select all that apply. A. A client with hepatitis B B. A client with herpes zoster C. A client with pyelonephritis D. A client with hashimotos thyroiditis E. A client with a urinary tract infection 4.ID: 9476805554 The home health nurse is caring for an older client recovering from pneumonia. A concerned family member believes that the client is no longer capable of caring for self effectively. The nurse conducts an assessment of the client’s basic activities of daily living (BADLs). What activities would the nurse assess? Select all that apply. A. Eating B. Bathing C. Cooking D. Dressing E. Taking medications F. Balancing a checkbook 5.ID: 9476807948 The nurse is caring for a client who has recently undergone a right-sided mastectomy for stage 3 breast cancer. When giving report to the next shift, what information would be essential to communicate to the oncoming nurse? Select all that apply. A. Elevate the right arm on a pillow. B. Monitor skin color and for the presence of edema. C. Educate that a medical alert bracelet is being worn. D. Ensure the client refrains from any physical activity. E. Take blood pressure measurements on the right side only. 6.ID: 9476793886 A client informs the nurse that she has recently started taking the herbal supplement black cohosh for her menopausal symptoms. When reviewing the client’s medical record, what finding would warrant the need for follow-up? Refer to chart. Hi s t o r y a n d Ph y s i c a l Laboratory Results Medi cat io ns Re n a l In Thyroid Stimulating Hormone (TSH) 2.45 mIU/L Gl ipi zi de 5m g s u f f ic ie n c y or al on ce da ily He a r t f a i l u r e B-type natriuretic peptide (BNP) 204 pg/ml Si m va st at in 40m g on ce da ily A. TSH result B. BNP result C. Heart failure D. Glipizide prescription 7.ID: 9476797805 A client is admitted to hospital for treatment of a respiratory infection. The client was treated with an intravenous (IV) course of ampicillin and is ready to be discharged home on oral antibiotics. What information present in the chart would warrant the nurse to provide further teaching? Hist ory and Phy sica l Labo rator y and Diag nosti c Findi ngs Medi catio ns Ane Ches t X- Ray: norg esti mate mia cons olida tion in left uppe r lobe and ethin yl estra diol oral once daily PolyCysticOvarianSyn drome(PCOS) Potassium level of 4.5 meq/ L Metformin 500 mg oral twice daily A. Anemia B. Potassium result C. Chest X-ray result D. Norgestimate and ethinyl estradiol prescription 8.ID: 9476797864 The charge nurse is making a client assignment for the upcoming shift. In order to create a safe assignment, the charge nurse plans to assign those clients requiring airborne precautions amongst different nurses. Which clients should be assigned to different nurses? Select all that apply. A. A client with measles. B. A client with C. difficle. C. A client with influenza. D. A client with pneumonia. E. A client with tuberculosis. 9.ID: 9476801200 The nurse at an outpatient clinic is performing a health assessment on a 67 year-old client. Her health history includes chronic obstructive pulmonary disorder (COPD) and diabetes mellitus and she currently has no complaints. On assessment, the client tells the nurse that she has not received any vaccinations other than a tetanus vaccine four years ago. Which routine vaccinations should be recommended given the client’s age? Select all that apply. A. Tetanus vaccine B. Shingles vaccine C. Influenza vaccine D. Rotavirus vaccine E. Pneumococcal vaccine 10.ID: 9476801225 The nurse at a long-term care facility is conducting a medication review of a newly admitted older client with dementia, hypertension, diabetes mellitus, and depression. Which medication prescription would warrant the need to contact the health care provider? Select all that apply. A. Lisinopril 10 mg orally once daily. B. Furosemide 20mg orally once daily. C. Fluoxetine 20 mg orally once daily. D. Metformin 500mg orally twice daily. E. Cyclobenzaprine 5mg every 8 hours as needed. 11.ID: 9476801253 The nurse is assisting in the examination of a five year old child who was removed from an abusive home. The social worker alerts the nurse that there is a history of violence in the child’s home, which has resulted in the removal of the child and siblings. Which behaviors should the nurse expect the child to express? Select all that apply. A. Smiling during the exam. B. Blaming the abuser for the injury. C. A need to find and protect a sibling. D. Feeling guilty for causing the abuse to occur. E. Aggressive behavior towards the nurse and health care provider. 12.ID: 9476797879 The nurse is examining an infant with burns that are suspicious for child abuse. Which findings should the nurse report as highly suspicious for abuse? (Select all that apply). A. A burn mark on the child’s finger. B. Circular burn marks on the infant’s buttocks. C. A bright pink coloring on the infant’s cheeks. D. A dark brown marking on the infant’s lower back. E. A stocking pattern of burn marks on the infant’s feet and legs. 13.ID: 9476801241 The nurse is volunteering at a local health fair to educate the public on primary prevention of stress. Which interventions would be the most appropriate for the nurse to recommend to the public, in order to reduce stress levels? Select all that apply. A. Finding a source of pleasure. B. Developing a positive attitude. C. Counseling for chronic anxiety. D. Engaging in stressful situations. E. Learning relaxation and deep breathing exercises. 14.ID: 9476805564 The nurse is assisting a family with end-of-life care for their child. Which actions by the nurse would be the most appropriate? Select all that apply. F. Acknowledging the emotions of the family members. G. Taking time to listen to the family talk about their child. H. Limiting communication with the family, to allow grieving. I. Reminding the family that their feelings and emotions are normal. J. Gently reminding the family that they must focus on their remaining children. 15.ID: 9476797841 A pregnant client has a history of depression and has been noncompliant with treatment in the past. What actions by the nurse would be the most appropriate? Select all that apply. A. Respect the client's decisions. B. Maintain a hopeful, caring relationship with the client. C. Discuss the noncompliance with the client, if the client brings it up. D. Provide education to the client about depression and treatment options. E. Ask the client what methods of managing the depression have worked in the past. 16.ID: 9476807900 The nurse is caring for a client who is in labor and preparing for birth. The nurse has been advised that the pregnancy is the result of a rape. Which statements by the nurse would be the most appropriate? Select all that apply. A. "You are safe here." B. "We have done this many times before." C. "Just relax; we know what we are doing." D. "You are in labor and preparing to give birth to your baby." E. "You do not need to be concerned about anything because your baby is ok." 17.ID: 9476793873 The nurse is attending an educational session on substance abuse during pregnancy. Which statements by the nurse indicate that the education has been effective? Select all that apply. A. "Substance abuse generally has no effect on the fetus." B. "Social stigma, labeling, and guilt are barriers to treatment." C. "Pregnant women often do not seek help for fear of losing their child." D. "Most pregnant women end up receiving treatment for their addictions." E. "In some states, pregnant women who abuse substances may face criminal charges." 18.ID: 9476793860 The nurse is assessing a client who is two days post-partum, and preparing to be discharged from the health care facility. Which interventions would be the most appropriate for the nurse to perform? Select all that apply. A. Assess the client for risk factors of depression. B. Determine if a follow-up after discharge is necessary. C. Provide a listing of community resources to the client and family. D. Spend time observing the interactions between the client and infant. E. Educate the client and family on the signs of post-partum depression. 19.ID: 9476812010 The nurse on a post-partum floor is assessing a client for signs of post-partum depression. Which statements would be the most appropriate for the nurse to make, in order to assess the client for depression? Select all that apply. A. "How are things going for you today?" B. "Do you have anyone to help you at home?" C. "Can you tell me how you are feeling today?” D. "I'm sure you're so happy with your new baby". E. "It is not very common to feel sad after giving birth". 20.ID: 9476797870 The nurse manager is educating a group of nursing students on the educational needs of bariatric clients post-surgery. Which statement by one of the nursing students indicates that the teaching has been effective? Select all that apply. A. "The client should be encouraged to keep follow-up appointments." B. "During weight loss, the client may become depressed or even anxious." C. "Clients should be provided with a list of available community resources." D. "It is not necessary for clients to adhere to a community-based treatment plan." E. "Clients are followed by a surgeon and dietician for a few months after the surgery." 21.ID: 9476810150 The nurse is monitoring a client who is receiving a blood transfusion. The blood has been infusing for 15 minutes. The nurse interprets which assessment findings as a possible allergic reaction? Select all that apply. A. Increased pallor B. New onset of hypertension C. The client reports feeling nervous D. Palpation of a rapid, thready pulse E. A change in the client’s level of fatigue 22.ID: 9476812018 The nurse is assessing the client for placement of a midline catheter. Which factors would prompt the nurse to select a different type of catheter for this client? Select all that apply. A. Dialysis fistula on the right arm B. The use of vesicant medications C. The need for long-term antibiotics D. Client history of bilateral mastectomy with lymphedema E. The need for parenteral therapy with osmolarity greater than 600 mOsm/L (600 mmol/kg) F. 23.ID: 9476793868 The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The health care provider has just started the client on methotrexate, to manage symptoms. When creating the plan of care for this client, which adverse effects should the nurse monitor for? Select all that apply. A. Increased thirst B. Elevated blood pressure C. Elevation of liver enzymes D. A decrease in the platelet count E. An increase in white blood cells (WBC) 24.ID: 9476793878 The nurse is creating a plan of care for a client with chronic pain. Which alternative therapies should the nurse add into the plan, to increase the client’s comfort? Select all that apply. A. Providing therapeutic massage B. Play soft music during rest times C. Assist with a warm, soothing bath D. Educate the client to plan for rest time E. Increase the client’s dosage of pain medication 25.ID: 9476805542 The nurse is caring for a client who has had a myocardial infarction. After administering intravenous morphine sulfate, which interventions should the nurse take? Select all that apply. A. Monitor the client’s blood pressure B. Monitor the client’s respiratory rate C. Determine the client’s oxygen saturation D. Ask the client to obtain a urine specimen E. Prepare the client for cardiac catheterization 26.ID: 9476801235 The nurse is caring for a client with known chronic kidney disease (CKD), who is taking digoxin. When assessing the client, which signs/symptoms would alert the nurse to the possibility of digoxin toxicity? Select all that apply. A. Anorexia B. Muscle aches C. Visual changes D. Sudden ear pain E. Nausea and vomiting 27.ID: 9476807913 The nurse is creating a plan of care for a client who was admitted with an infection. The nurse has been informed that the client will need a peripherally inserted central catheter (PICC) line placed, and in the next few days will be discharged home. Which information about the PICC line should the nurse include in the plan of care? Select all that apply. A. Avoid heavy lifting once B. Keep the extremity immobile C. How to care for the PICC line D. Reason for PICC line placement E. How to get dressed with the PICC line 28.ID: 9476810136 On assessment of a client with a normal saline intravenous (IV) infusion, the nurse notes that the IV site has infiltrated. Which actions by the nurse would be appropriate? Select all that apply. A. Stop the IV infusion B. Elevate the extremity C. Apply a warm compress to the IV site D. Apply a sterile dressing if weeping occurs E. Restart a new IV below the current IV site 29.ID: 9476810110 The nurse has been assigned a client who is receiving enalapril therapy. After receiving report and looking at the client’s chart, which action should the nurse take first? A. Obtain a blood pressure B. Perform a full physical assessment C. Administer the client’s morning medications D. Order the client’s breakfast tray to be delivered at 0800 30.ID: 9476801260 The nurse is preparing to administer bumetanide to a client. What information is the priority for the nurse to obtain prior to administering this medication? A. The client’s current weight B. The client’s potassium level C. The time of the client’s last meal D. The time of the last bumetanide administration 31.ID: 9476801299 Which clients are at high risk for venous thromboembolism (VTE)? Select all that apply. A. A 35 year-old with intractable nausea B. A 88 year-old admitted with confusion C. A 28 year-old recovering from a paralytic ileus D. A 45 year-old recovering from a total hysterectomy E. A 45 year-old in a motor vehicle accident who sustained multiple fractures 32.ID: 9476801214 The nurse in the emergency department is caring for a client just brought in with partial thickness burns to 50% of the body. What actions should the nurse implement as part of the care plan? Select all that apply. A. Elevate extremities B. Administer tetanus vaccine for prophylaxis C. Assess airway patency and provide oxygen as needed D. Provide the client with a large glass of water to stay hydrated E. Keep burns uncovered to allow for cooling air to reach the wounds 33.ID: 9476805536 The nurse caring for an 8 month old child at the pediatrician’s office is reviewing medication instructions with the father. The client has otitis media and has been prescribed amoxicillin 250 mg three times daily. The medication comes as a liquid suspension of 500 mg/10 mL. The nurse would advise the father to give how many milliliters per dose? Fill in the blank and round answer to the nearest whole number. milliliters 34.ID: 9476797881 The nurse is instructing a postoperative client how to use a demand-only patient controlled analgesia (PCA) pump. What statements made by the client would indicate teaching was effective? Select all that apply. A. “This machine will deliver pain medication when I push the button.” B. “I should push the button as many times as I want if I have any pain at all.” C. “Itching is a normal side effect and I do not need to worry if I experience this.” D. “If I fall asleep, my wife can push the button for me so I continue to get pain medication.” E. “My oxygen and breathing will be monitored while using this machine to prevent being over medicated.” 35.ID: 9476801274 The nurse is caring for a client with Addison’s disease in acute crisis. What priority actions should the nurse implement into the care plan? Select all that apply. A. Apply telemetry monitoring B. Monitor strict intake and output C. Administer spironolactone as prescribed D. Rapidly infuse normal saline as prescribed E. Administer oxygen via non-rebreather mask 36.ID: 9476805582 A client asks the nurse what can be done to prevent colon cancer as his father passed away from it. What information would be appropriate for the nurse to include in the teaching? Select all that apply. A. Limit alcohol consumption and avoid smoking B. Screening for colon cancer should begin at age 60 C. A diet high in fat can increase your risk of colon cancer D. Fiber can irritate the gastrointestinal tract and should be limited E. Notify your healthcare provider of any changes in your bowel habits 37.ID: 9476805576 The nurse on the labor and delivery unit notes the following fetal heart rate pattern on the fetal monitoring strip (refer to figure). What is the priority nursing action? A. Assist client to the supine position B. Increase oxytocin (Pitocin) infusion C. Administer oxygen via face mask at 8 to 10 L D. Continue to monitor fetal heart rate patterns 38.ID: 9476801257 A 22-year-old African American woman is 28 weeks pregnant. She is concerned about pre-term labor and asks the nurse what she should look out for. What statements made by the client would indicate the need for further teaching? Select all that apply. A. “I should stay well hydrated.” B. “I am at a higher risk because of my race.” C. “Stress levels can impact my chance of preterm labor.” D. “My age puts me at a higher risk of having the baby early.” E. “As long as I’m not obese, my weight does not increase my risk.” 39.ID: 9476797818 The nurse on a medical surgical telemetry unit notes an abnormal cardiac rhythm. After quickly assessing the client, which cardiac rhythm would indicate the need for immediate cardiopulmonary resuscitation (CPR)? Refer to figures 1-4. A. B. C. D. 40.ID: 9476805593 A client with diabetes mellitus, heart failure, and hypertension is being seen by the health care provider. The health care provider prescribes lispro insulin pens at mealtime. The client asks the nurse how to store the insulin pens. The nurse should include what information in the teaching? Select all that apply. A. Once opened, insulin pens are good for one month. B. When traveling, do not store the insulin pens in a warm car. C. The insulin pens should be stored in the refrigerator at all times. D. Keep the insulin pens away from children, for example on a high windowsill. E. Unopened insulin pens may be stored in the freezer to lengthen the shelf life. 41.ID: 9476793849 The nurse is discharging an older client who was admitted for dehydration. Which instructions would be the most appropriate for the nurse to include in the discharge teaching? Select all that apply. A. Drink caffeine in moderation. B. Avoid drinking water right before bed. C. Eliminate juice drinks totally from the diet. D. Understand how prescribed medications work. E. Be sure to drink 6 to 8 glasses of water each day. 42.ID: 9476801290 The nurse is working at a health fair, educating the public on how to prevent heat-related illnesses. Which information would be the most appropriate for the nurse to provide? Select all that apply. A. Avoid alcohol and caffeine B. Wear sunscreen of at least SPF 30 C. Limit activity at the hottest time of day D. Wear clothing suited to the environment E. Heat illnesses only occur to those who work outside 43.ID: 9476801206 The nurse is working in the emergency department when a client is brought in by ambulance. The client reports being bitten by a North American pit viper. Upon assessment, the nurse notices a bite mark on the client’s left leg. Which actions should the nurse to take? Select all that apply. A. Apply ice to the bite mark B. Initiate cardiac monitoring C. Prepare to administer oxygen D. Start two large-bore intravenous (IV) lines E. Measure the circumference of the bitten extremity every 15 to 30 minutes 44.ID: 9476793898 The emergency department nurse has just received a client who was struck by lightning. On initial assessment, the nurse notes a pulse and that the client is breathing. Which actions should the nurse to take? Select all that apply. A. Monitor for rhabdomyolosis. B. Prepare the client for discharge. C. Assess for occult traumatic injuries. D. Request a creatinine kinase measurement. E. Perform a 12-lead electrocardiogram (ECG). 45.ID: 9476801228 The nurse is at a local pool when alerted of a near drowning event. Which actions should the nurse take? Select all that apply. A. Send a by-stander to call for help B. Obtain client history from a family member C. Initiate cardiopulmonary resuscitation (CPR) D. Maintain spinal immobilization immediately E. Handle the client gently to prevent ventricular fibrillation 46.ID: 9476801245 The nurse is caring for a client with urinary calculi, who is preparing for a surgical procedure to remove the stones. Which action by the nurse is a priority for maintaining the client’s psychosocial integrity? A. Administer pain medications upon the client’s request B. Teach the client actions to take after the procedure if problems arise C. Prepare the client’s consent form and chart to transport to the surgical area D. Explain to the client that the surgeon will provide education on the procedure 47.ID: 9476805547 The nurse is providing discharge instructions to a client who has been diagnosed with cystitis. The nurse has been notified that the client does not have health care insurance. Which instruction from the nurse would be the most important for the client to complete in order to continue treatment? A. Follow up with a health care provider within one week. B. Call the case manager, in order to arrange payment for care. C. Fill the prescriptions that have been provided by the health care provider. D. Review the provided list of available community resources and initiate contact. 48.ID: 9476793894 The nurse in an assisted living facility is providing care to an older client, who has just moved to the facility. Which actions should the nurse include in the plan of care to decrease relocation stress, and help the client adjust to the new environment? Select all that apply. A. Take the time to assess the client’s usual lifestyle. B. Explain each procedure to the client as they occur. C. Allow the client to participate in decision making activities. D. Establish a trusting relationship with the client as soon as possible. E. Ask the client’s family to refrain from bringing special keepsakes to the facility. 49.ID: 9476793854 The nurse is caring for a client with chronic pain. Which actions should the nurse take, in order to assess the client’s quality of life? Select all that apply. A. Withhold pain medications to determine the client’s need. B. Ask if the client has difficulty sleeping or eating due to pain. C. Ask the client about the side effects of prescribed medication. D. Ask the client to describe how the pain has affected the daily routine. E. Ask the client if there are activities that are no longer possible due to pain. 50.ID: 9476797872 The nurse is caring for a client with severe anxiety. What should the nurse include when creating the care plan for this client? Select all that apply. A. The client will understand when to seek treatment. B. The client will be able to perform deep breathing exercises. C. The client will state where to obtain support group information. D. The client will state when it is appropriate to ignore the symptoms. E. The client will understand how medication helps stop panic attacks. 51.ID: 9476807975 The nurse reviewing the surgeon’s prescriptions in preparation for the client’s surgery. Which of the Surgical Care Improvement Project (SCIP) core measures does the nurse identify as appropriate? Select all that apply. A. Electric clippers are used to remove hair B. Indwelling catheter will be removed on post-operative day 4 C. Prophylactic antibiotic will be initiated 15 minutes prior to surgical incision D. Prophylactic antibiotics discontinued within 24 hours after surgery end time E. Temperature will be measured 15 minutes after the end of anesthesia administration 52.ID: 9476797812 The emergency department nurse is caring for a client at risk for respiratory failure. Which nursing actions are important in the care of this client? Select all that apply. A. Listen to breath sounds B. Evaluate chest expansion C. Assess for trauma to the chest D. Look for physical abnormalities E. Request a needle decompression 53.ID: 9476810166 The nurse works in a busy emergency department and would like to reduce the potential for adverse events. Which actions can the nurse take to accomplish this? Select all that apply. A. Wash hands frequently B. Utilize automated electronic track systems C. Look through the client’s belongings for medication bottles D. Obtain an accurate medical history from the client or family E. Look for the presence of medical alert bracelets or necklaces 54.ID: 9476807941 The nurse is counseling a client who has been diagnosed with the human immune deficiency virus (HIV). In creating a plan of care, which interventions should the nurse include? Select all that apply. A. Instruct the client not to share towels B. Discuss options for medication therapy C. Educate the client about proper condom use D. Provide education about needle exchange programs E. Discuss the client’s HIV status and ensure understanding 55.ID: 9476807993 The nurse is providing education to the client who is receiving external radiation therapy to the face. Which statements by the client indicate understanding? Select all that apply. A. “It is okay to wash off the ink or dye markings.” B. “I should not use soap at all when washing my face.” C. “I need to avoid exposing the irradiated area to the sun.” D. “I should use my hands to wash my face, rather than a washcloth.” E. “I can use lotions or powders that are prescribed by the radiation oncology department.” 56.ID: 9476797845 The nurse is caring for a client with cancer who has just been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). On assessment, the client complains of weakness, muscle cramps, and loss of appetite. Which specific actions should the nurse include in the plan of care? Select all that apply. A. Check for peripheral edema B. Monitor the client for a bounding pulse C. Monitor the client for neck vein distention D. Assess for the presence of crackles in the lungs E. Observe urine for changes in color or characteristic 57.ID: 9476807966 The nurse is listening to an information presentation on the new objectives for Healthy People 2020. Which statements by the nurse indicate an understanding of the objectives? Select all that apply. A. “One of the objectives is to increase the 1 year survival rates for infants with Down Syndrome.” B. “Healthy People 2020 will aim to increase the percentage of women ages 18 to 44 who have impaired fecundity.” C. “An objective of Healthy People 2020 is to increase the percentage of employers who have worksite lactation programs.” D. “Healthy People 2020 will strive to increase the percentage of newborns to receive formula supplementation during the first two days of life.” E. “Healthy People 2020 aim to increase the percentage of live births that occur in facilities that provide recommended care to lactating mother and their babies.” . 58.ID: 9476805508 The nurse is creating a plan of care for a client who is planning to become pregnant. What should the nurse include in the plan to help the client have a good pregnancy outcome? Select all that apply. A. Eat a healthy diet B. Avoid the use of alcohol and tobacco C. Prevent sexually transmitted infections D. Refrain from exercising during preconception E. Take the recommended amount of folic acid each day 59.ID: 9476793841 The nurse is caring for a client in labor. During assessment, the nurse notes that the client is hypotensive and that the fetus has an abnormal heart rate pattern. Which interventions should the nurse take? Select all that apply. A. Prepare the client for a cesarean section B. Encourage the client to ambulate in the room C. Place the client in a lateral or trendelenburg position D. Prepare the client for induction of labor with oxytocin E. Increase the rate of the primary intravenous (IV) infusion 60.ID: 9476801265 The nurse is caring for a client with neutropenia. To monitor for infection, which action by the nurse is a priority? A. Listen to lung sounds B. Encourage a nutritious diet C. Take the client’s vital signs every shift D. Place the client in a room close to the nurse’s station E. 61.ID: 9476805525 The nurse is providing care to a client following thoracentesis. Which actions should the nurse add to the client’s plan of care, in order to promote health and safety? Select all that apply. A. Monitor vital signs as prescribed B. Assess the dressing for bleeding C. Ensure that a chest x-ray is obtained D. Instruct the client to avoid deep breathing E. Auscultate breath sounds for absent or reduced sounds 62.ID: 9476797802 The nurse is preparing the client for a bronchoscopy. Which actions should the nurse take to ensure client safety? Select all that apply. A. Explain the procedure to the client B. Clarify and document the client’s allergies C. Verify the client using two types of identifiers D. Keep the client NPO for 2 hours prior to the test E. Ensure that pre-procedure laboratory studies are drawn 63.ID: 9476807933 The nurse is providing care to a client who has a tracheostomy. Which actions should the nurse take to prevent a tube obstruction? Select all that apply. A. Provide inner cannula care B. Suction the tube as needed C. Humidify the oxygen source D. Assess the client every shift for tube patency E. Teach the client how to cough and deep breathe 64.ID: 9476801209 The nurse is creating a plan of care for a client with a chest tube. Which actions should the nurse include to promote client safety? Select all that apply. A. Position the drainage tubing to prevent kinks B. Strip the chest tube as needed to improve suction C. Check the system every 4 hours to ensure patency D. Tape tubing junctions to prevent accidental disconnections E. Keep sterile gauze and padded clamps (per agency procedure) at the bedside 65.ID: 9476812024 A client will be started on peritoneal dialysis. The nurse should consider which statements in planning care for the client? Select all that apply. A. Bowel perforation is very rare. B. The client may experience respiratory distress. C. The client will require a diet that is high in protein. D. A complication of peritoneal dialysis is hyperglycemia. E. The client will experience few hemodynamic complications. 66.ID: 9476797854 A client with left-sided heart failure has arrived on the cardiac unit. Which actions should the nurse initially include in the care plan for this client? Select all that apply. A. Take the apical heart rate for one minute B. Toilet the client every hour and as needed C. Teach the client how to regulate breathing D. Allow the client rest time between activities E. Allow the client to walk in the hallway a few times a day as desired 67.ID: 9476801249 Upon assessment of a client with heart failure, the nurse notes that the client is dyspneic. Which actions should the nurse take initially? Select all that apply. A. Prepare the client for intubation B. Place the client in the Trendelenburg position C. Place pillows under each of the client’s arms D. Assist the client with deep breathing exercises E. Administer oxygen to keep O2 saturation greater than 90% 68.ID: 9476807923 The home care nurse is providing care to a client with heart failure. Which assessment findings should alert the nurse to worsening heart failure? Select all that apply. A. Pallor B. Confusion C. Chest pain D. Warm extremities E. Activity intolerance 69.ID: 9476801223 The nurse is assessing a client with mitral valve regurgitation. Which manifestations should the nurse expect to note? Select all that apply. A. Fatigue B. Orthopnea C. Chronic weakness D. Low blood pressure E. Atypical chest pains Awarded 3.0 points out of 4.0 possible points. 70.ID: 9476797885 The nurse is caring for a client with infective endocarditis, who is preparing to be discharged home. Which self-management techniques should the nurse teach the client? Select all that apply. A. Brush teeth once a day, with a soft toothbrush. B. Take prescribed antibiotics exactly as directed. C. Follow instructions for care for the infusion site. D. Clean open sores and apply prescribed antibiotic ointment. E. Ask the health care provider for prophylactic antibiotics prior to invasive procedures. [Show More]

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